ASUHAN KEPERAWATAN

PADA Px. ........ DENGAN PENYAKIT .....................................

DIRUANG.............................................. RS..............................................

NAMA : ....................................................................................
NIM : ....................................................................................

PROGRAM STUDY PROFESI NERS

STIKes BINA SEHAT KAB. MOJOKERTO
T.A 2018 – 2019
 LEMBAR PENGESAHAN

Laporan Asuhan Keperawatan ini diajukan oleh :

Nama : ............................................................................
NIM : ............................................................................
Program Studi : ............................................................................
Judul Asuhan Keperawatan :
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Telah diperiksa dan disetujui sebagai tugas dalam praktik klinik keperawatan
maternitas.

............................ , ............................
Pembimbing Ruangan, Pembimbing Akademik,

(..............................................) (..............................................)

Mengetahui,
Kepala Ruangan,

(..............................................)
 FORMAT ASUHAN KEPERAWATAN MATERNITAS (GINEKOLOGI)
PROGRAM STUDI PROFESI NERS
STIKes BINA SEHAT PPNI KAB. MOJOKERTO

I. PENGKAJIAN
Tanggal MRS : ..............................................
Ruang : ..............................................
No. Register : ..............................................
Diagnosa Medis : ..............................................
Tanggal Pengkajian : ..............................................

A. IDENTITAS PASIEN :
- Nama : ..............................................
- Umur : ..............................................
- Suku/Bangsa : ..............................................
- Bahasa : ..............................................
- Pekerjaan : ..............................................
- Status : ..............................................
- Alamat : ..............................................
- Nama Suami : ..............................................
- Pekerjaan : ..............................................

B. STATUS KESEHATAN
1. KELUHAN UTAMA
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2. RIWAYAT KESEHATAN SEKARANG
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3. RIWAYAT PENYAKIT DAHULU
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4. RIWAYAT PENYAKIT KELUARGA
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KEADAAN UMUM :
Tanda – tanda vital : Nadi : ___ x/menit
Suhu : ___ OC
RR : ___ x/menit
TD : ___/___ mmHg

II. PEMERIKSAAN FISIK

1. B1 (BREATING)
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2. B2 (BLOOD)
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3. B3 (BRAIN)
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4. B4 (BLADDER)
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5. B5 (BOWEL)
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 6. B6 (BONE)
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III. PEMERIKSAAN PENUNJANG

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IV. TERAPI
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 ANALISA DATA

Nama Pasien : No. Reg :

NO DATA ETIOLOGI MASALAH
 DAFTAR DIAGNOSIS

Nama Pasien : No. Reg :

NO DIAGNOSIS KEPERAWATAN TTD

3
 RENCANA KEPERAWATAN

Nama Pasien : No. Reg :

No. TUJUAN & KRITERIA
INTERVENSI RASIONAL
DX HASIL
 IMPLEMENTASI KEPERAWATAN

Nama Pasien : No. Reg :

No.
WAKTU IMPLEMENTASI TTD
DX
 EVALUASI KEPERAWATAN

Nama Pasien : No. Reg :

No. EVALUASI
TTD
DX S-O-A-P